URI Normal Course

Acute Rhinosinusitis

Defined as up to 4 weeks of purulent (not clear) nasal drainage accompanied by nasal obstruction (congestion), facial pain/pressure/fullness, or both
Symptoms most highly predictive of acute sinusitis (viral or bacterial): purulent rhinorrhea + nasal congestion and/or facial pain/pressure

	Acute viral rhinosinusitis (viral URI)	Acute bacterial rhinosinusitis (ABS)	Recurrent acute rhinosinusitis	Acute invasive fungal rhinosinusitis
Clinical Features or Definition	Typically resolves 7-10 days but progress to bacterial sinusitis in 0.5-2%	Up to 75% resolve without treatment in 4 weeks Most common cause is classically S. pneumoniae, H. influenzae (nontypeable), and M. catarrhalis H. flu appears to have become more common and S. pneumo less common as causes of ABS in children Rates of beta-lactamase production in H. flu have increased in many geographic areas In children typically presents as viral URI that persists >10 days without improvement, or worsening of URI symptoms after initial improvement, or severe symptoms (fever, purulent rhinorrhea) for 3-4 days	Definition Acute rhinosinusitis >3 times per year ≥2 of the cardinal signs of sinusitis Normal between episodes	Disease of immunosuppressed or poorly controlled diabetics Rapidly progressive and life-threatening intravascular tissue invasion by fungi (Mucor, Rhizopus, Aspergillus, Absidia and Basidiobolus)
Treatment (Adult)	Primarily supportive treatment indicated: Acetaminophen, NSAIDs Irrigation with buffered hypertonic saline Intranasal steroids Topical, oral decongestant Intranasal ipratroprium 1st generation (drying) antihistamines Approach to acute rhinosinusitis (Kaliner) Hydration (6-8 glasses of water per day) Oxymetazoline BID x 3-7 days Nasal saline sinus rinse BID Nasal steroid 2 sprays each nostril BID Analgesics PRN Antibiotics if symptoms persist >7-10 days	Supportive treatment (as for viral URI) Watchful waiting up to 1 week if mild pain and temp <101 F Antibiotics 1st line: Amoxicillin 500 mg PO TID x 10-14 days PCN allergic: TMP-SMX or azithromycin Treatment failure (symptoms fail to improve in 7 days or worsen): Levofloxacin 500 mg PO QD, high dose amox/clav 4g/250 mg/day Consider sinus CT to confirm diagnosis Relapse within 2 weeks: If had improved significantly on original antibiotics: repeat same antibiotic with longer course If minimal improvement: repeat course with different antibiotic	Same as acute bacterial rhinosinusitis	Emergent ENT referral, surgical debridement, systemic anti-fungal therapy
Treatment (Pediatric)	Supportive treatment (as above) though less evidence for their effectiveness in children Cough/cold medications typically not recommended for children <6 years	Supportive treatment (as for viral URI) though less evidence for their effectiveness in children For persistent acute ABS (nasal discharge of any quality, cough, or both, persisting for >10 days without improvement) may observe for 3 additional days before starting antibiotics For double sickening or severe symptoms (fever≥39 C, purulent nasal discharge for ≥3 days) may start antibiotics Antibiotics (AAP 2013) Duration of treatment 10-14 days but consider continuing until symptom free + 1 week more Azithro/clarithromycin and TMP-SMX are no longer recommended due to high rates of resistance among both S. pneumo and H. flu isolates If uncomplicated, mild-moderate severity, no day care, no antibiotics in past 30 days: Amox 45 mg/Kg/d div PO BID Amox 90 mg/Kg/d div PO BID (max 4 g/d) in communities with high prevalence of resistant S. pneumo If uncomplicated, moderate/severe severity, attend daycare, or taken antibiotics in past 90 days: Amox/clav 80-90 mg/Kg/d of amox component and 6.4 mg/Kg/d of clav div PO BID (max amox 4 g/d) Cefdinir 14 mg/Kg/d PO QD or div BID Cefuroxime 30 mg/Kg/d PO div BID Cefpodoxime 10 mg/Kg/d PO div BID Cefixime 8 mg/Kg/d If unable to tolerate PO: Ceftriaxone 50 mg/Kg IM q24 then switch to PO when not vomiting PCN allergy: Cephalosporin likely safe (but consider allergist) For the rare patient with mod/severe ABS, severe allergy to PCNs and <2 yo: Levofloxacin liquid 16 mg/Kg/d PO div BID Clindamycin 30-40 mg/Kg/d PO div TID + cefixime If treatment with amox/clav fails >72 hours, switch to levofloxacin (covers S. pneumo, H. flu, M. cat) or a combination of clindamycin (for S. pneumo) + cefixime (for H. flu and M. cat) or linezolid 20-30 mg/Kg/d div BID-TID (for S. pneumo) + cefixime may be offered (see below)	Same as acute bacterial rhinosinusitis	Emergent ENT referral, surgical debridement, systemic anti-fungal therapy